- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $5,495.41 / $7,762.47
| Facility | | $1,348.96 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,288.25 / $1,513.56
| Professional | | $912.01 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,737.80 / $15,135.61
| Professional | | $1,174.90 | $1,737.80 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,344.23 / $3,630.78
| Professional | | $1,202.26 | $2,344.23 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,511.89 / $3,019.95
| Professional | | $1,513.56 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,489.63 / $41,686.94
| Facility | | $4,897.79 | $13,489.63 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,380.38 / $3,467.37
| Professional | | $602.56 | $1,380.38 | $3,467.37 |